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Arjomandi Rad A, Zubarevich A, Osswald A, Vardanyan R, Magouliotis DE, Ansaripour A, Kourliouros A, Sá MP, Rassaf T, Ruhparwar A, Sardari Nia P, Athanasiou T, Weymann A. The Surgical Treatment of Infective Endocarditis: A Comprehensive Review. Diagnostics (Basel) 2024; 14:464. [PMID: 38472937 DOI: 10.3390/diagnostics14050464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/08/2024] [Accepted: 02/18/2024] [Indexed: 03/14/2024] Open
Abstract
Infective endocarditis (IE) is a severe cardiac complication with high mortality rates, especially when surgical intervention is delayed or absent. This review addresses the expanding role of surgery in managing IE, focusing on the variation in surgical treatment rates, the impact of patient demographics, and the effectiveness of different surgical approaches. Despite varying global data, a notable increase in surgical interventions for IE is evident, with over 50% of patients undergoing surgery in tertiary centres. This review synthesizes information from focused literature searches up to July 2023, covering preoperative to postoperative considerations and surgical strategies for IE. Key preoperative concerns include accurate diagnosis, appropriate antimicrobial treatment, and the timing of surgery, which is particularly crucial for patients with heart failure or at risk of embolism. Surgical approaches vary based on valve involvement, with mitral valve repair showing promising outcomes compared to replacement. Aortic valve surgery, traditionally favouring replacement, now includes repair as a viable option. Emerging techniques such as sutureless valves and aortic homografts are explored, highlighting their potential advantages in specific IE cases. The review also delves into high-risk groups like intravenous drug users and the elderly, emphasizing the need for tailored surgical strategies. With an increasing number of patients presenting with prosthetic valve endocarditis and device-related IE, the review underscores the importance of comprehensive management strategies encompassing surgical and medical interventions. Overall, this review provides a comprehensive overview of current evidence in the surgical management of IE, highlighting the necessity of a multidisciplinary approach and ongoing research to optimize patient outcomes.
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Affiliation(s)
- Arian Arjomandi Rad
- Medical Sciences Division, University of Oxford, Oxford OX3 9DU, UK
- Department of Surgery and Cancer, Imperial College London, London SW7 5NH, UK
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
| | - Alina Zubarevich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Anja Osswald
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Robert Vardanyan
- Department of Surgery and Cancer, Imperial College London, London SW7 5NH, UK
| | | | - Ali Ansaripour
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Antonios Kourliouros
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Michel Pompeu Sá
- Department of Cardiothoracic Surgery, UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Tienush Rassaf
- Department of Cardiology, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, 45138 Essen, Germany
| | - Arjang Ruhparwar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Peyman Sardari Nia
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, London SW7 5NH, UK
| | - Alexander Weymann
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
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Nappi F, Avtaar Singh SS, Jitendra V, Fiore A. Bridging Molecular and Clinical Sciences to Achieve the Best Treatment of Enterococcus faecalis Endocarditis. Microorganisms 2023; 11:2604. [PMID: 37894262 PMCID: PMC10609379 DOI: 10.3390/microorganisms11102604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/14/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
Enterococcus faecalis (E. faecalis) is a commensal bacterium that causes various infections in surgical sites, the urinary tract, and blood. The bacterium is becoming a significant concern because it tends to affect the elderly population, which has a high prevalence of undiagnosed degenerative valvular disease and is often subjected to invasive procedures and implanted medical devices. The bacterium's actions are influenced by specific characteristics like pili activity and biofilm formation. This resistance significantly impedes the effectiveness of numerous antibiotic therapies, particularly in cases of endocarditis. While current guidelines recommend antimicrobial therapy, the emergence of resistant strains has introduced complexity in managing these patients, especially with the increasing use of transcatheter therapies for those who are not suitable for surgery. Presentations of the condition are often varied and associated with generalised symptoms, which may pose a diagnostic challenge. We share our encounter with a case study that concerns an octogenarian who had a TAVI valve and developed endocarditis. We also conducted a literature review to identify the essential treatment algorithms for such cases.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
| | | | - Vikram Jitendra
- Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, UK;
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Creteil, France;
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Nappi F, Schoell T, Spadaccio C, Acar C, da Costa FDA. A Literature Review on the Use of Aortic Allografts in Modern Cardiac Surgery for the Treatment of Infective Endocarditis: Is There Clear Evidence or Is It Merely a Perception? Life (Basel) 2023; 13:1980. [PMID: 37895362 PMCID: PMC10608498 DOI: 10.3390/life13101980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/18/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023] Open
Abstract
Infective valve endocarditis is caused by different pathogens and 60% of those involve the aortic valve with valve failure. Although S. aureus is recognized as the most frequently isolated causative bacterium associated with IE in high-income countries, Gram-positive cocci nevertheless play a crucial role in promoting infection in relation to their adhesive matrix molecules. The presence of pili on the surface of Gram-positive bacteria such as in different strains of Enterococcus faecalis and Streptococcus spp., grants these causative pathogens a great offensive capacity due to the formation of biofilms and resistance to antibiotics. The indications and timing of surgery in endocarditis are debated as well as the choice of the ideal valve substitute to replace the diseased valve(s) when repair is not possible. We reviewed the literature and elaborated a systematic approach to endocarditis management based on clinical, microbiological, and anatomopathological variables known to affect postoperative outcomes with the aim to stratify the patients and orient decision making. From this review emerges significant findings on the risk of infection in the allograft used in patients with endocarditis and no endocarditis etiology suggesting that the use of allografts has proved safety and effectiveness in patients with both pathologies.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France;
| | - Thibaut Schoell
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France;
| | - Cristiano Spadaccio
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NP, UK;
| | - Christophe Acar
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47-83, 75013 Paris, France;
| | - Francisco Diniz Affonso da Costa
- Department of Cardiovascular Surgery, Instituto de Neurologia e Cardiologia de Curitiba—INC Cardio, Curitiba 81210-310, Parana, Brazil;
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Sergeevichev D, Vasiliyeva M, Kuznetsova E, Chelobanov B. Preservation of Mechanical and Morphological Properties of Porcine Cardiac Outflow Vessels after Decellularization and Wet Storage. Biomimetics (Basel) 2023; 8:315. [PMID: 37504203 PMCID: PMC10807022 DOI: 10.3390/biomimetics8030315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/12/2023] [Accepted: 07/15/2023] [Indexed: 07/29/2023] Open
Abstract
Widely used storage methods, including freezing or chemical modification, preserve the sterility of biological tissues but degrade the mechanical properties of materials used to make heart valve prostheses. Therefore, wet storage remains the most optimal option for biomaterials. Three biocidal solutions (an antibiotic mixture, an octanediol-phenoxyethanol complex solution, and a glycerol-ethanol mixture) were studied for the storage of native and decellularized porcine aorta and pulmonary trunk. Subsequent mechanical testing and microstructural analysis showed a slight increase in the tensile strength of native and decellularized aorta in the longitudinal direction. Pulmonary trunk elongation increased 1.3-1.6 times in the longitudinal direction after decellularization only. The microstructures of the tested specimens showed no differences before and after wet storage. Thus, two months of wet storage of native and decellularized porcine aorta and pulmonary trunks does not significantly affect the strength and elastic properties of the material. The wet storage protocol using alcohol solutions of glycerol or octanediol-phenoxyethanol mixture may be intended for further fabrication of extracellular matrix for tissue-engineered biological heart valve prostheses.
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Affiliation(s)
- David Sergeevichev
- NMRC Named after Academician E.N. Meshalkin of the Ministry of Health of the Russian Federation, Novosibirsk 630055, Russia
- Vorozhtsov Institute of Organic Chemistry SB RAS, Novosibirsk 630090, Russia
| | - Maria Vasiliyeva
- V. Zelman‘s Institute of Medicine and Psychology, Novosibirsk State University, Novosibirsk 630090, Russia
| | - Elena Kuznetsova
- NMRC Named after Academician E.N. Meshalkin of the Ministry of Health of the Russian Federation, Novosibirsk 630055, Russia
| | - Boris Chelobanov
- Institute of Chemical Biology and Fundamental Medicine SB RAS, Novosibirsk 630090, Russia
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Nappi F, Avtaar Singh SS. Host-Bacterium Interaction Mechanisms in Staphylococcus aureus Endocarditis: A Systematic Review. Int J Mol Sci 2023; 24:11068. [PMID: 37446247 DOI: 10.3390/ijms241311068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/21/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023] Open
Abstract
Staphylococci sp. are the most commonly associated pathogens in infective endocarditis, especially within high-income nations. This along with the increasing burden of healthcare, aging populations, and the protracted infection courses, contribute to a significant challenge for healthcare systems. A systematic review was conducted using relevant search criteria from PubMed, Ovid's version of MEDLINE, and EMBASE, and data were tabulated from randomized controlled trials (RCT), observational cohort studies, meta-analysis, and basic research articles. The review was registered with the OSF register of systematic reviews and followed the PRISMA reporting guidelines. Thirty-five studies met the inclusion criteria and were included in the final systematic review. The role of Staphylococcus aureus and its interaction with the protective shield and host protection functions was identified and highlighted in several studies. The interaction between infective endocarditis pathogens, vascular endothelium, and blood constituents was also explored, giving rise to the potential use of antiplatelets as preventative and/or curative agents. Several factors allow Staphylococcus aureus infections to proliferate within the host with numerous promoting and perpetuating agents. The complex interaction with the hosts' innate immunity also potentiates its virulence. The goal of this study is to attain a better understanding on the molecular pathways involved in infective endocarditis supported by S. aureus and whether therapeutic avenues for the prevention and treatment of IE can be obtained. The use of antibiotic-treated allogeneic tissues have marked antibacterial action, thereby becoming the ideal substitute in native and prosthetic valvular infections. However, the development of effective vaccines against S. aureus still requires in-depth studies.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
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Nappi F, Nenna A, Spadaccio C, Avtaar Singh SS, Almazil A, Acar C. The Use of the Cryopreserved Aortic Homograft for Aortic Valve Replacement: Is It Still an Option? J Cardiovasc Dev Dis 2023; 10:248. [PMID: 37367413 DOI: 10.3390/jcdd10060248] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/28/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023] Open
Abstract
The indications for cryopreserved allografts in aortic valve replacement are still debatable. We aim to identify factors influencing early and long-term durability of the aortic homograft and to define subgroups of patients with an improved long-term quality of life, survival, and freedom from structural valve degeneration (SVD). We evaluated our series of 210 patients who underwent allograft implantation with a retrospective cohort study design over a period of 20 years. Endpoints were overall mortality, cardiac mortality related to SVD, the incidence of SVD, reoperation, and a composite endpoint comprising major adverse cardiac and cerebrovascular events (MACCEs), which includes cardiac death both related and not related to SVD, subsequent aortic valve surgery, new or recurrent infection of implanted allograft, recurrent aortic regurgitation, rehospitalization for heart failure, an increase in New York Heart Association (NYHA) class of ≥1, or cerebrovascular events. The primary indication for surgery was endocarditis (48%), which was also a predisposing factor for increased cardiac mortality. Overall mortality was 32.4% with a 27% incidence of SVD and mortality associated with SVD of 13.8%. Reoperation occurred in 33.8% and MACCEs in 54.8%. Long-term NYHA functional class and echocardiographic parameters improved over time. Statistical analysis demonstrated that root replacement technique and adult age were protective factors for SVD. We found no statistically significant difference in the clinical outcomes analyzed between women of childbearing age who had children after surgery and the rest of the women. The cryopreserved allograft is still a valid option in aortic valve replacement, providing acceptable durability and clinical outcomes with optimal hemodynamic performance. SVD is influenced by the implantation technique. Women of childbearing age might have additional benefits from this procedure.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint Denis, France
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 00128 Roma, Italy
| | - Cristiano Spadaccio
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NP, UK
| | | | - Almothana Almazil
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint Denis, France
| | - Christophe Acar
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47-83, 75013 Paris, France
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Skific M, Golemovic M, Safradin I, Duric Z, Biocina B, Golubic Cepulic B. Cryopreserved human heart valve allografts: a ten-year single centre experience. Cell Tissue Bank 2022; 24:401-416. [PMID: 36222968 PMCID: PMC9555264 DOI: 10.1007/s10561-022-10043-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/21/2022] [Indexed: 11/29/2022]
Abstract
This study provides an overview of tissue banking activities at the Croatian Cardiovascular Tissue Bank (CTB) during past ten years and presents the outcomes of cryopreserved heart valve allografts (CHAs) use in different patient groups. From June 2011 until December 2021, 75 heart donations were referred to CTB: 41 recipient of heart transplant (RHT), 32 donors after brain death (DBD) and 2 donors after circulatory death (DCD) donations. Processing resulted in 103 valves of which 65 met quality requirements for clinical use. Overall tissue discard rate was 37%. The most frequent reasons for discard were inadequate morphology (12%) in RHT donations and microbiological contamination (19%) in DBD donations. Altogether, 38 CHAs were transplanted to 36 patients. Recipients were divided in three groups; infective endocarditis (IE), non-infectious heart disease and congenital heart disease group. In the IE group, the 30-day, 1-year and 3-year survival was 71%, 53% and 47%, respectively. Freedom from re-operation due to all graft-related causes was 76% and due to structural valve deterioration 88%. There were no cases of graft reinfection. In the congenital heart disease group CHAs were predominantly (94%) used for right ventricular outflow tract reconstruction and 88% of patients recovered without graft-related complications. At present, the number of demands for CHAs at CTB considerably outweighs their availability.
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Affiliation(s)
- Marijana Skific
- Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia.
| | - Mirna Golemovic
- Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia
| | - Ivica Safradin
- Department of Cardiac Surgery, University Hospital Centre Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia
| | - Zeljko Duric
- Department of Cardiac Surgery, University Hospital Centre Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia
| | - Bojan Biocina
- Department of Cardiac Surgery, University Hospital Centre Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia.,University of Zagreb School of Medicine, Salata 3, 10000, Zagreb, Croatia
| | - Branka Golubic Cepulic
- Clinical Department of Transfusion Medicine and Transplantation Biology, University Hospital Centre Zagreb, Kispaticeva 12, 10000, Zagreb, Croatia.,University of Zagreb School of Medicine, Salata 3, 10000, Zagreb, Croatia.,University of Applied Health Sciences, Mlinarska 38, 10000, Zagreb, Croatia.,University of Split, University Department of Health Studies, Rudera Boskovica 35, 21000, Split, Croatia
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Nappi F, Avtaar Singh SS, Nappi P, Fiore A. Biomechanics of Transcatheter Aortic Valve Implant. Bioengineering (Basel) 2022; 9:bioengineering9070299. [PMID: 35877350 PMCID: PMC9312295 DOI: 10.3390/bioengineering9070299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 11/16/2022] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has grown exponentially within the cardiology and cardiac surgical spheres. It has now become a routine approach for treating aortic stenosis. Several concerns have been raised about TAVI in comparison to conventional surgical aortic valve replacement (SAVR). The primary concerns regard the longevity of the valves. Several factors have been identified which may predict poor outcomes following TAVI. To this end, the lesser-used finite element analysis (FEA) was used to quantify the properties of calcifications which affect TAVI valves. This method can also be used in conjunction with other integrated software to ascertain the functionality of these valves. Other imaging modalities such as multi-detector row computed tomography (MDCT) are now widely available, which can accurately size aortic valve annuli. This may help reduce the incidence of paravalvular leaks and regurgitation which may necessitate further intervention. Structural valve degeneration (SVD) remains a key factor, with varying results from current studies. The true incidence of SVD in TAVI compared to SAVR remains unclear due to the lack of long-term data. It is now widely accepted that both are part of the armamentarium and are not mutually exclusive. Decision making in terms of appropriate interventions should be undertaken via shared decision making involving heart teams.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
- Correspondence: ; Tel.: +33-149334104; Fax: +33-149334119
| | | | - Pierluigi Nappi
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy;
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Creteil, France;
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The New Challenge for Heart Endocarditis: From Conventional Prosthesis to New Devices and Platforms for the Treatment of Structural Heart Disease. BIOMED RESEARCH INTERNATIONAL 2021; 2021:7302165. [PMID: 34222484 PMCID: PMC8219429 DOI: 10.1155/2021/7302165] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/02/2021] [Indexed: 01/07/2023]
Abstract
Infective endocarditis is a sinister condition with considerable morbidity and mortality. Its relevance in the current era is compounded by the increased use of implanted devices such as replacement valves or cardiac implantable electronic devices. These infections are caused by multiple different bacteria with different virulence, pathogenicity, and antimicrobial resistance. Unlike in native endocarditis, the presence of foreign tissue permits sustenance by inflammatory and thrombotic processes as the artificial surfaces promote inflammatory responses and hypercoagulability. Prevention of these infections has been suggested with the use of homografts in combination with antibiotics. Others have attempted to use "low fouling coats" with little clinical success thus far. The use of antibiotic prophylaxis plays a pivotal part in reducing the incidence of prosthesis-related endocarditis. This remains especially crucial with the increasing use of transcatheter heart valve therapies. The widespread use of cardiac implantable electronic devices such as permanent pacemakers, implantable cardioverter defibrillators, and cardiac resynchronization therapy devices has also heralded a noticeable increase in cases of infectious endocarditis affecting complex equipment which can be difficult to treat. Multimodality strategies are needed with input from surgeons and cardiologists to ensure treatment is both prompt and successful, tailored to the individual needs of the patients.
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Witten JC, Durbak E, Houghtaling PL, Unai S, Roselli EE, Bakaeen FG, Johnston DR, Svensson LG, Jaber W, Blackstone EH, Pettersson GB. Performance and Durability of Cryopreserved Allograft Aortic Valve Replacements. Ann Thorac Surg 2021; 111:1893-1900. [DOI: 10.1016/j.athoracsur.2020.07.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 07/02/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022]
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Percutaneous versus Surgical Intervention for Severe Aortic Valve Stenosis: A Systematic Review. BIOMED RESEARCH INTERNATIONAL 2021; 2021:3973924. [PMID: 34136565 PMCID: PMC8175165 DOI: 10.1155/2021/3973924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/04/2021] [Accepted: 05/14/2021] [Indexed: 11/18/2022]
Abstract
Aortic stenosis is a disease that is increasing in prevalence and manifests as decreased cardiac output, which if left untreated can result in heart failure and ultimately death. It is primarily a disease of the elderly who often have multiple comorbidities. The advent of transcatheter aortic valve therapies has changed the way we treat these conditions. However, long-term results of these therapies remain uncertain. Recently, there has been an increasing number of studies examining the role of both surgical aortic valve replacement and transcatheter aortic valve replacement. We therefore performed a systematic review using Ovid MEDLINE, Ovid Embase, and the Cochrane Library. Two investigators searched papers published between January 1, 2007, and to date using the following terms: "aortic valve stenosis," "aortic valve operation," and "transcatheter aortic valve therapy." Both strategies in aortic stenosis treatment highlighted specific indications alongside the pitfalls such as structural valve degeneration and valve thrombosis which have a bearing on clinical outcomes. We propose some recommendations to help clinicians in the decision-making process as technological improvements make both surgical and transcatheter therapies viable options for patients with aortic stenosis. Finally, we assess the role of finite element analysis in patient selection for aortic valve replacement. THVT and AVR-S are both useful tools in the armamentarium against aortic stenosis. The decision between the two treatment strategies should be best guided by a strong robust evidence base, ideally with a long-term follow-up. This is best performed by the heart team with the patient as the center of the discussion.
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Scialla S, Martuscelli G, Nappi F, Singh SSA, Iervolino A, Larobina D, Ambrosio L, Raucci MG. Trends in Managing Cardiac and Orthopaedic Device-Associated Infections by Using Therapeutic Biomaterials. Polymers (Basel) 2021; 13:1556. [PMID: 34066192 PMCID: PMC8151391 DOI: 10.3390/polym13101556] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 12/23/2022] Open
Abstract
Over the years, there has been an increasing number of cardiac and orthopaedic implanted medical devices, which has caused an increased incidence of device-associated infections. The surfaces of these indwelling devices are preferred sites for the development of biofilms that are potentially lethal for patients. Device-related infections form a large proportion of hospital-acquired infections and have a bearing on both morbidity and mortality. Treatment of these infections is limited to the use of systemic antibiotics with invasive revision surgeries, which had implications on healthcare burdens. The purpose of this review is to describe the main causes that lead to the onset of infection, highlighting both the biological and clinical pathophysiology. Both passive and active surface treatments have been used in the field of biomaterials to reduce the impact of these infections. This includes the use of antimicrobial peptides and ionic liquids in the preventive treatment of antibiotic-resistant biofilms. Thus far, multiple in vivo studies have shown efficacious effects against the antibiotic-resistant biofilm. However, this has yet to materialize in clinical medicine.
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Affiliation(s)
- Stefania Scialla
- Institute of Polymers, Composites and Biomaterials of National Research Council (IPCB-CNR), 80125 Naples, Italy; (S.S.); (D.L.)
| | - Giorgia Martuscelli
- Multidisciplinary Department of Medical-Surgical and Dental Specialties, University of Campania Luigi Vanvitelli, 81100 Naples, Italy;
| | - Francesco Nappi
- Centre Cardiologie du Nord de Saint-Denis, Department of Cardiac Surgery, 93200 Paris, France; (F.N.); (A.I.)
| | | | - Adelaide Iervolino
- Centre Cardiologie du Nord de Saint-Denis, Department of Cardiac Surgery, 93200 Paris, France; (F.N.); (A.I.)
| | - Domenico Larobina
- Institute of Polymers, Composites and Biomaterials of National Research Council (IPCB-CNR), 80125 Naples, Italy; (S.S.); (D.L.)
| | - Luigi Ambrosio
- Institute of Polymers, Composites and Biomaterials of National Research Council (IPCB-CNR), 80125 Naples, Italy; (S.S.); (D.L.)
| | - Maria Grazia Raucci
- Institute of Polymers, Composites and Biomaterials of National Research Council (IPCB-CNR), 80125 Naples, Italy; (S.S.); (D.L.)
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13
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De Palo M, Scicchitano P, Malvindi PG, Paparella D. Endocarditis in Patients with Aortic Valve Prosthesis: Comparison between Surgical and Transcatheter Prosthesis. Antibiotics (Basel) 2021; 10:antibiotics10010050. [PMID: 33419074 PMCID: PMC7825452 DOI: 10.3390/antibiotics10010050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 12/25/2020] [Accepted: 01/03/2021] [Indexed: 12/25/2022] Open
Abstract
The interventional treatment of aortic stenosis is currently based on transcatheter aortic valve implantation/replacement (TAVI/TAVR) and surgical aortic valve replacement (SAVR). Prosthetic valve infective endocarditis (PVE) is the most worrisome complication after valve replacement, as it still carries high mortality and morbidity rate. Studies have not highlighted the differences in the occurrence of PVE in SAVR as opposed to TAVR, but the reported incidence rates are widely uneven. Literature portrays different microbiological profiles for SAVR and TAVR PVE: Staphylococcus, Enterococcus, and Streptococcus are the pathogens that are more frequently involved with differences regarding the timing from the date of the intervention. Imaging by means of transoesophageal echocardiography, and computed tomography (CT) Scan is essential in identifying vegetations, prosthesis dysfunction, dehiscence, periannular abscess, or aorto-ventricular discontinuity. In most cases, conservative medical treatment is not able to prevent fatal events and surgery represents the only viable option. The primary objectives of surgical treatment are radical debridement and the removal of infected tissues, the reconstruction of cardiac and aortic morphology, and the restoration of the aortic valve function. Different surgical options are discussed. Fast diagnosis, the adequacy of antibiotics treatment, and prompt interventions are essential in preventing the negative consequences of infective endocarditis (IE).
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Affiliation(s)
- Micaela De Palo
- Section of Cardiac Surgery, A.O.U. Consorziale Policlinico di Bari, 70124 Bari, Italy
- Correspondence: (M.D.P.); (D.P.); Tel.: +39-080-559-4404 (M.D.P.); +39-080-919-9162 (D.P.)
| | - Pietro Scicchitano
- Section of Cardiology, F. Perinei Hospital, Altamura, 70022 Bari, Italy;
| | | | - Domenico Paparella
- Division of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, 70124 Bari, Italy
- Department of Medical and Surgical Science, University of Foggia, 71122 Foggia, Italy
- Correspondence: (M.D.P.); (D.P.); Tel.: +39-080-559-4404 (M.D.P.); +39-080-919-9162 (D.P.)
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Melina G, De Robertis F, Gaer JA, Angeloni E, El-Hamamsy I, Bahrami T, Pepper JR, Takkenberg JJM, Yacoub MH. Long-term survival after xenograft versus homograft aortic root replacement: Results from a prospective randomized trial. J Thorac Cardiovasc Surg 2021; 161:57-65. [PMID: 31735388 DOI: 10.1016/j.jtcvs.2019.09.119] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 09/01/2019] [Accepted: 09/04/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The study objective was to investigate the long-term survival of patients undergoing xenograft versus homograft full root aortic valve replacement. METHODS A total of 166 patients requiring aortic valve surgery were randomized to undergo the Freestyle (Medtronic Inc, Minneapolis, Minn) bioprosthesis (N = 90) or a homograft (N = 76) full root aortic valve replacement between 1997 and 2005 in a single institution. Six patients randomly assigned to the homograft crossed over to the Freestyle bioprosthesis because of the unavailability of suitably sized homografts. All surgeons were required to adhere to the standard surgical technique for homograft root implantation previously described. Follow-up was 98.5% complete. RESULTS The mean age of the study population was 65 ± 8 years. Coronary artery bypass grafting was associated with root aortic valve replacement in 76 of 166 patients (46%, P = not significant between groups), and overall hospital mortality was 4.8% (8/166, P = not significant between groups). Median follow-up was 13.8 years (range, 0-21.8 years; 2033 patient-years). The Kaplan-Meier survival analysis showed that there was no significant difference in overall survival between the 2 arms at 5, 10, and 15 years. Twenty-year survival was 28.3% ± 5% for the Freestyle group versus 25.1% ± 5.7% for the homograft group (P = .90), which was comparable to the age- and sex-matched UK general population. The freedom from aortic valve reoperation at 20 years was comparable for the Freestyle group versus the homograft group (67.9% ± 8.8% vs 67.2% ± 10.3%, respectively; P = .74). CONCLUSIONS This is the first study to investigate the long-term survival of xenograft versus homograft full root aortic valve replacement from a prospective randomized trial. The observed 20-year overall survival and freedom from aortic valve reoperation serve as a benchmark for future studies on interventions for aortic valve disease in the elderly.
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Affiliation(s)
- Giovanni Melina
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom; Department of Cardiac Surgery, Ospedale Sant'Andrea, "Sapienza" Università di Roma, Rome, Italy
| | - Fabio De Robertis
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Jullien A Gaer
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Emiliano Angeloni
- Department of Cardiac Surgery, Ospedale Sant'Andrea, "Sapienza" Università di Roma, Rome, Italy
| | - Ismail El-Hamamsy
- Division of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Toufan Bahrami
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - John R Pepper
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
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15
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Benedetto U, Spadaccio C, Gentile F, Moon MR, Nappi F. A narrative review of early surgery versus conventional treatment for infective endocarditis: do we have an answer? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1626. [PMID: 33437825 PMCID: PMC7791236 DOI: 10.21037/atm-20-3880] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The most appropriate strategy and timing for surgery in infective endocarditis (IE) remains an argument of debate. Despite some authors promote the adoption of an early surgical approach (within 48 hours) to limit mortality and complications, no robust randomized trials are available on this argument and the evidence on this subject remain at the "expert opinion" level. Additionally, the different messages promulgated by the American and European guidelines contributed to fuel confusion regarding the relative priority of the surgical over medical therapy in IE. The European Society of Cardiology (ESC) guidelines individuates three level of urgency: emergency surgery, to be performed within 24 hours; urgent surgery, recommended within a few days; elective surgery to be performed after 1-2 weeks of antibiotic therapy. Urgent surgery is recommended for most cases of IE. In the American Heart Association (AHA)'s guidelines define early surgery as "during the initial hospitalization and before completion of a full course of antibiotics." Some of the available evidences showed that are no proven benefits in delaying surgery if a definite diagnosis of IE has been established. However, this argument is controversial across the literature and several factors including the center specific experience can play a role in decision-making. In this review the latest evidences on IE clinical and surgical characteristics along with the current studies on the adoption of an early surgical approach are analyzed to clarify whether enough evidence is available to inform an update of the guidelines.
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Affiliation(s)
- Umberto Benedetto
- Department of Cardiothoracic Surgery, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Cristiano Spadaccio
- Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | | | - Marc R Moon
- Department of Cardiac Thoracic Surgery, Washington University School of Medicine, Saint Louis, MO, USA
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
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16
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Pollari F, Spadaccio C, Cuomo M, Chello M, Nenna A, Fischlein T, Nappi F. Sharing of decision-making for infective endocarditis surgery: a narrative review of clinical and ethical implications. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1624. [PMID: 33437823 PMCID: PMC7791252 DOI: 10.21037/atm-20-4626] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Infective endocarditis (IE) is nowadays one of the most challenging disease in cardiac surgery because of its multifaceted clinical and anatomical presentation. Despite the many clinical and surgical advances achieved in the past 60 years, there is a lack of evidence regarding the ideal strategy. The present review aims to investigate and highlight two main novel concepts for the decision-making of the best substitute. Firstly, the concept of an "endocarditis team": a coordinated multidisciplinary effort in the diagnostic work-up, especially in conditions of high risk of embolization or clinical deterioration. A good "endocarditis team" has the role to overcome such problem, in order to ensure a prompt and balanced strategy. Secondly, which ethical considerations are required to drive the choice of valvular substitute. The choice of best valve substitute is a relevant issue of debate, not only with operative but also prognostic and accordingly ethical aftermaths. Many different solutions have been developed to substitute the infected valve. Among these: mechanical prosthesis (MP), biological stented prosthesis (BP), sutureless bioprosthesis and cryopreserved homografts (CHs). Patients need to be informed in detail about the technical issues pertaining the use of these valve substitute. We will discuss the evidences regarding the risk of recurrent infections or future potentially severe calcification of aortic homograft valve and wall (in other words, the failure of the homograft) and the difficulties in managing the reoperation.
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Affiliation(s)
- Francesco Pollari
- Department of Cardiac Surgery, Klinikum Nürnberg-Paracelsus Medical University, Nuremberg, Germany
| | - Cristiano Spadaccio
- Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Michela Cuomo
- Division of Pediatric Cardiac Surgery, University of Erlangen, Erlangen, Germany
| | - Massimo Chello
- Department of Cardiovascular Surgery, University Campus Bio-Medico of Rome, Rome, Italy
| | - Antonio Nenna
- Department of Cardiovascular Surgery, University Campus Bio-Medico of Rome, Rome, Italy
| | - Theodor Fischlein
- Department of Cardiac Surgery, Klinikum Nürnberg-Paracelsus Medical University, Nuremberg, Germany
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
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17
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Nappi F, Spadaccio C, Moon MR. A management framework for left sided endocarditis: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1627. [PMID: 33437826 PMCID: PMC7791223 DOI: 10.21037/atm-20-4439] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Left sided endocarditis (LSE) can include the entirety or portion of mitral and/or aortic valve and the structures in their anatomical contiguity and represent a significant portion of emergency surgical activity. Literature and guidelines on the management of LSE relies mainly on observational studies given the difficulty in designing randomized trials in emergency settings. Heart teams (HT) are often called in to difficult decisions on the most appropriate strategy to adopted in case of LSE. Decision-making should take into account the localization and the extension of the infection, patient preoperative status and comorbidities, presence of a previous valve prosthesis and best timing for surgery. Despite evidence suggests that early surgery may improve survival in patients with complicated infective endocarditis (IE), an increased risk of recurrence and postoperative valvular dysfunctions has been reported. The most important factors associated with long-term outcomes are preoperative multiorgan failure, prosthetic mechanical valve IE, vegetation size ≥15 mm, and timing of surgical treatment. Importantly, up to one third of potential candidates do not undergo surgery and these patients experience extremely high mortality rates. Another important point regards the choice of the optimal valve substitute to be used according to the different clinical situation. The lack of RCT in this field and the difficulty to design this type of studies in the case of non-elective conditions further complicates the possibility to achieve a univocal consensus on the best strategy to be adopted in each form of LSE and further validation studies are needed. On the basis of the current evidences a decisional algorithm is proposed summarizing all the crucial aspects in the management of LSE.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Cristiano Spadaccio
- Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, UK.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Marc R Moon
- Department of Cardiac Thoracic Surgery, Washington University School of Medicine, St Louis, Missouri, USA
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18
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Kislitsina ON, Szlapka M, McCarthy PM, Davidson CJ, Flaherty JD, Sweis RN, Kruse J, Andrei AC, Cox JL, Malaisrie SC. Unique technical challenges in patients undergoing TAVR for failed aortic homografts. J Card Surg 2020; 36:89-96. [PMID: 33170533 DOI: 10.1111/jocs.15176] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/31/2020] [Accepted: 09/30/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Surgical reoperation for aortic homograft structural valve degeneration (SVD) is a high-risk procedure. Transcatheter aortic valve replacement (TAVR) for homograft-SVD is an alternative to reoperation, but descriptions of implantation techniques are limited. This study compares outcome in patients undergoing into two groups by the type of previously implanted aortic valve prosthesis: TAVR for failed aortic homografts (TAVR-H) or for stented aortic bioprostheses (TAVR-BP). METHODS From 2015 to 2017, TAVR was performed in 41 patients with SVD. Thirty-three patients in the TAVR-BP group (six for SVD of valved conduits), and eight patients in the TAVR-H group. The Valve Academic Research Consortium criteria were used for outcome reporting purposes. RESULTS The patients with TAVR-BP had predominant prosthetic stenosis (94%, p = .002), whereas TAVR-H individuals presented mostly with regurgitation (88%, p = <.001). Patients with TAVR-H received: Sapien-3 (6), Sapien-XT (1), and CoreValve (1) devices. Low, 40% ventricular fixation in relation to homograft annulus was attempted to anchor the prosthesis on the homograft suture-line. One patient with TAVR-BP experienced intraoperative distal prosthesis migration and Type-B aortic dissection, and two patients in the TAVR-H group had late postoperative proximal device migration. In both groups, there was zero 30-day mortality, stroke, or pacemaker implantation. CONCLUSIONS TAVR for failing aortic homografts may be a feasible and safe alternative to high-risk surgical reintervention. Precise, 40%-ventricular device positioning appears crucial for prevention of late paravalvular leak/late prosthesis migration and minimizing the risk of repeat surgical intervention.
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Affiliation(s)
- Olga N Kislitsina
- Divisions of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA.,Divisions of Cardiology, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - Michal Szlapka
- Divisions of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - Patrick M McCarthy
- Divisions of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - Charles J Davidson
- Divisions of Cardiology, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - James D Flaherty
- Divisions of Cardiology, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - Ranya N Sweis
- Divisions of Cardiology, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - Jane Kruse
- Divisions of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - Adin C Andrei
- Department of Preventive Medicine, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - James L Cox
- Divisions of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - S Christopher Malaisrie
- Divisions of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
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19
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Nappi F, Avtaar Singh SS, Timofeeva I. Learning From Controversy: Contemporary Surgical Management of Aortic Valve Endocarditis. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820960729. [PMID: 33088184 PMCID: PMC7545763 DOI: 10.1177/1179546820960729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 08/30/2020] [Indexed: 12/27/2022]
Abstract
Aortic valve replacement is the commonest cardiac surgical operation performed worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are goals of the procedure. However, no detailed guidelines on prosthesis selection and surgical strategies guided by the comprehensive evaluation of the extension of the infection and its microbiological characteristics, clinical profile of the patient, and risk of infection recurrence are currently available. Conventional mechanical or stented xenografts are the preferred choice for localized aortic infection. However, in cases of complex IE with the involvement of the root or the aortomitral continuity, the use of homograft is suggested according to the surgeon and center experience. Homograft use should be counterbalanced against the risk of structural degeneration. Prosthetic bioroot or prosthetic valved conduit (mechanical and bioprosthetic) are also potentially suitable alternatives. Further development of preservation techniques enabling longer durability of allogenic substitutes is required. We evaluate the current evidence for the use of valve substitutes in aortic valve endocarditis and propose an evidence-based algorithm to guide the choice of therapy. We performed a systemic review to clarify the contemporary surgical management of aortic valve endocarditis.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Irina Timofeeva
- Department of Imaging, Centre Cardiologique du Nord de Saint-Denis, Paris, France
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20
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Nappi F, Singh SSA, Spadaccio C, Acar C. Revisiting the guidelines and choice the ideal substitute for aortic valve endocarditis. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:952. [PMID: 32953752 PMCID: PMC7475423 DOI: 10.21037/atm-20-1522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Aortic valve replacement is the most commonly performed cardiac surgical operation worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are the treatment goals. However, no detailed guidelines on prosthesis selection and surgical strategy are available. Management should be guided by a comprehensive evaluation of infection extension and its microbiological characteristics, the clinical profile of the patient and the risk of infection recurrence. We conducted a literature search of the PubMed database, EMBASE and Cochrane Library (through November 2019) for studies reporting to the use of biological substitutes in aortic valve endocarditis (AVE). Studies comparing long-term outcomes in the use of allogenic and autologous with conventional prostheses were investigated. Conventional mechanical or stented xenografts are the preferred choice for localized aortic infection. In cases of complex IE with the involvement of the root or the aorto-mitral continuity, the use of homografts are recommended, according to surgeon's and center experience. Homograft use needs to be balanced against the risk of structural degeneration. Prosthetic bioroot or prosthetic valved conduit with a mechanical or bioprosthetic valve are acceptable alternatives. The choice of aortic valves substitute and surgical strategy in IE is multifaceted. Principles guiding the selection of prosthesis and surgical approach rely on the long-term durability and the avoidance of infection relapse. A decisional algorithm considering the extension of the infection and its microbiological characteristics, the clinical profile of the patient and the risk of infection recurrence is provided. A multidisciplinary effort is required to achieve consistent outcomes.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, North Cardiological Center, Saint-Denis, Paris, France
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, UK.,University of Glasgow Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Cristiano Spadaccio
- Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, UK.,University of Glasgow Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Christophe Acar
- Department of Cardiovascular Surgery, Heart Institute, la Pitie Salpetriere Hospital, Paris, France
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21
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Abdelsattar ZM, Elsisy MF, Schaff H, Stulak J, Greason K, Pochettino A, Arghami A, Rowse P, Bagameri G, Khullar V, Daly R, Cicek S, Dearani J, Crestanello J. Comparative Effectiveness of Mechanical Valves and Homografts in Complex Aortic Endocarditis. Ann Thorac Surg 2020; 111:793-799. [PMID: 32890491 DOI: 10.1016/j.athoracsur.2020.06.082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/07/2020] [Accepted: 06/17/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The ideal surgical reconstruction of the aortic root in patients with complex endocarditis is controversial. We compared the short- and long-term outcomes between mechanical valves, bioprostheses, and homografts. METHODS We identified all patients undergoing an operation for active complex aortic endocarditis at our institution between 2003 and 2017. We grouped patients according to those who received a mechanical valve, bioprosthesis, or homograft. We used multiple logistic regression and proportional hazards models. To minimize confounding by indication, we used marginal risk adjustment to simulate that every patient would undergo (contrary to fact) all 3 operations. RESULTS Of 159 patients with complex active endocarditis, 48 (30.2%) had a valve plus patch reconstruction, and 85 (53.4%) had a root replacement. Of all, 50 (31.5%) had a mechanical valve, 56 (35.2%) had a bioprosthesis, and 53 (33.3%) had a homograft. The groups were similar in age, sex, body mass index, comorbid conditions, organism, abscess location, and mitral involvement (all P > .05). However, patients receiving mechanical reconstructions were more likely to have native valve endocarditis (46% vs 37.5% vs 17%; P = .005) and less likely to undergo root replacement (32% vs 28.6% vs 100%; P < .001). Marginal risk-adjusted operative mortality was lowest for mechanical valves (4.8%) and highest for homografts (16.9%; P = .041). Long-term survival after root replacement was worse with homografts than with mechanical valve conduits (adjusted hazard ratio, 2.9; P = .045). CONCLUSIONS In patients with complex endocarditis, mechanical valves are associated with similar, if not better, short- and long-term outcomes compared with homografts, even after adjusting for important baseline characteristics and limiting the analysis to root replacements only.
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Affiliation(s)
- Zaid M Abdelsattar
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota; Department of Thoracic and Cardiovascular Surgery, Loyola University Chicago, Chicago, Illinois
| | - Mohamed F Elsisy
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell Schaff
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - John Stulak
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kevin Greason
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Arman Arghami
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Philip Rowse
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Gabor Bagameri
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Vishal Khullar
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Richard Daly
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sertac Cicek
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Joseph Dearani
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota
| | - Juan Crestanello
- Department of Cardiac Surgery, Mayo Clinic, Rochester, Minnesota.
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Nappi F, Singh SSA, Lusini M, Nenna A, Gambardella I, Chello M. The use of allogenic and autologous tissue to treat aortic valve endocarditis. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:491. [PMID: 31700927 DOI: 10.21037/atm.2019.08.76] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The surgical treatment of aortic valve endocarditis (AVE) is generally performed using conventional mechanical or biological xenograft prosthesis, with limited use of aortic homograft (Ao-Homo) or pulmonary autograft (PA). Clinical evidence has demonstrated a clear contradiction between the proven benefits of Ao-Homo and PA in the context of infection and the very limited use of allogenic or autologous tissue in everyday clinical practice. This review aims to summarize the most recent and relevant literature in order to foster the scientific debate on the use of the use of allogenic and autologous tissue to treat AVE. The decisional process of the Heart Team should also include the preferences of the patient, his/her family, the general cardiologist or primary care physician. The use of allogenic or autologous valve substitute is beneficial if there is a high risk of recurrence of infection, avoiding extensive adhesiolysis and debridement of synthetic material. In any case, those procedures should be performed by highly trained centers to optimize outcomes.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, Paris, France
| | | | - Mario Lusini
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | | | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
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23
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Nappi F, Nenna A, Petitti T, Spadaccio C, Gambardella I, Lusini M, Chello M, Acar C. Long-term outcome of cryopreserved allograft for aortic valve replacement. J Thorac Cardiovasc Surg 2018; 156:1357-1365.e6. [PMID: 29759737 DOI: 10.1016/j.jtcvs.2018.04.040] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 02/12/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The most efficient surgical approach to severe aortic valve disease in the young adult is still debated: cryopreserved aortic allograft offers excellent hemodynamic and avoid anticoagulation, but long-term durability is influenced by structural valve deterioration (SVD). This study aimed to describe long-term results of aortic allografts and to identify factors influencing long-term durability. METHODS From January 1993 to August 2010, 210 patients underwent aortic allograft replacement via the free-hand subcoronary implantation technique (N = 55) or root replacement with coronary reimplantation (N = 155). Clinic and echocardiographic follow-up was updated to April 2016. RESULTS Overall mortality and cardiac mortality occurred in 80 (38.1%) and 64 (30.5%) patients, respectively. Reoperation was required in 69 cases (32.8%), whereas SVD required reoperation in 57 cases (27.1%). No early endocarditis occurred, whereas late endocarditis occurred in 4 patients. The free-hand technique seems to be associated with improved left ventricular remodeling compared with the root-replacement technique, and smaller allograft size represents a predictor of reoperation independently on the surgical technique used. In the overall population, there were 44 women of childbearing age, and 37 patients remained pregnant during the follow-up of the study. No differences were found in the clinical outcomes among women who had children and who did not. CONCLUSIONS Cryopreserved allograft is a valid option, especially in complex infective endocarditis and in women of childbearing age. A careful choice of allograft size and implantation technique can reduce the risk of SVD.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France.
| | - Antonio Nenna
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Tommasangelo Petitti
- Department of Public Health and Statistics, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom; University of Glasgow Institute of Cardiovascular and Medical Sciences, Glasgow, United Kingdom
| | - Ivancarmine Gambardella
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Mario Lusini
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Massimo Chello
- Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Christophe Acar
- Department of Cardiac Surgery, Hopital La Pitie Salpetriere, Paris, France
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24
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Greason KL. Aortic homografts, Einstein, and complexity. J Thorac Cardiovasc Surg 2016; 152:1580-1581. [PMID: 27842684 DOI: 10.1016/j.jtcvs.2016.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 09/12/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Kevin L Greason
- Department of Cardiovascular Surgery, Mayo Clinic Rochester, Rochester, Minn.
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